Tuberculosis in primary care

I was glad to see a primary care-based study and accompanying editorial on tuberculosis (TB).^1,2 For those of us working in areas where TB is no longer rare, reminders of the growing problem and diagnostic pitfalls are welcome. We know that at least one-half of TB cases are among people born abroad, in places where prevalence has always been high. In addition, among refugees arriving here, as many as 50% may be infected with TB; worldwide, over 17 000 refugees get sick with the disease every year.³ Tourism, international travel and migration are helping TB to spread. Other displaced people, such as homeless people in the UK, are at increased risk of being infected. Wherever it occurs, we need to recognise it is difficult to treat TB in mobile populations, and most of the challenge rightly falls on community and primary care services.

Yet, despite the Chief Medical Officer's action plan, there are still gaps in our management of TB in this country causing us to fall below internationally accepted standards of care. GPs deserve better, clearer guidelines on diagnosis and treatment, including:

• An emphasis on the need for sputum microscopy for detecting acid-fast bacilli as the definitive diagnostic test, with added value in public health terms of identifying infectious cases.⁴ Chest X-rays and other investigations are difficult to interpret and should not be recommended to GPs.

• On diagnosis, an explicit discussion with the patient to reach agreement on a treatment plan. GPs need to build a mutual accountability between patients and their key health worker (such as a community TB nurse, ideally). The rights of patients to confidentiality, the health worker to concordance, and the community to patient cure and contact tracing are complex and often neglected.⁵

• The adherence to standard uniform courses of treatment such as the highly effective WHO regimens. GPs are perfectly capable of initiating and monitoring treatment with these guidelines, and without them, are unnecessarily afraid of treating TB and leave it to respiratory physicians. There is plenty of evidence internationally that they are no better at curing TB with non-standard regimens, and consistency improves the chances of adherence to cure and the prevention of drug resistance.

Patients with TB want to be diagnosed and treated in the community with the support of their GP. Is it not time that the UK adopt a National TB Control Programme on international lines, and support primary care to deliver this?